Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

Pharmacy » Exceptions, Appeals & Grievances » Appointing a Representative

Appointing a Representative

If you need someone to file a grievance, coverage determination, organization determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are requesting an organization determination or coverage determination through an appointed representative, you should download form CMS-1696*, complete it, and mail it to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108

Fax (617) 426-1311

If you have any questions about naming your appointed representative, you can call us at 1‑866‑610‑2273 (TTY 711).

If you are treated unfairly or your rights are not respected

If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697), or call your local Office for Civil Rights.

If you believe you have been treated unfairly or your rights have not been respected, and it is not about discrimination, you can get help dealing with the problem by calling:

  • Commonwealth Care Alliance Member Services at 1-866-610-2273 (TTY 711)
  • Serving the Health Information Needs of Elders (SHINE) at 1-800-243-4636 (TTY 1‑800‑872‑0166)
  • Contacting Medicare/Medicaid by using their online form*

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*When you click this link, you will leave Commonwealth Care Alliance’s website.

Last Updated 07/29/2013